Claim Professional - Healthcare

Job Description - Claim Professional - Healthcare (052906)

Claim Professional - Healthcare

Capgemini is a global leader in consulting, digital transformation, technology and engineering services. The Group is at the forefront of innovation to address the entire breadth of clients’ opportunities in the evolving world of cloud, digital and platforms. Building on its strong 50-year+ heritage and deep industry-specific expertise, Capgemini enables organizations to realize their business ambitions through an array of services from strategy to operations.

Capgemini is driven by the conviction that the business value of technology comes from and through people. Today, it is a multicultural company of 270,000 team members in almost 50 countries. With Altran, the Group reported 2019 combined revenues of €17billion.

Capgemini is an Equal Opportunity Employer encouraging diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, national origin, gender identity/expression, age, religion, disability, sexual orientation, genetics, veteran status, marital status or any other characteristic protected by law.

This position requires in-depth knowledge of the Long Term Care industry and the claim process in its entirety.

• Responsible for accurate/timely daily review of Long Term Care claims and policy provisions to determine appropriate claim eligibility assessments
• Provide Excellent Customer Service to all external and internal stakeholders
• Responsible for timely request and follow-up request of any/all required additional information, i.e. medical records/notes, appropriate forms/documents, statements and/or certificates needed for proper claim adjudication
• Respond accurately, timely and professionally to all oral and written external and/or internal correspondences received from stakeholders in regard to benefits, eligibility, denials and appeals
• Responsible for any on-going LTC claim/case management and recertification of claim benefits
• Maintain current knowledge of LTC federal, state, and insurance regulations and requirements
• Maintain working knowledge of all company and services pertaining to business segment
• Maintain working knowledge and proficiency in company claims, administrative and imaging software systems such as Citron, Case 360, INSPRO and Microsoft applications
• Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines
• Interact professionally with other business units to gather and analyze data needed to properly determine appropriate claim eligibility and documentation of claims files

• Experience with Microsoft Word, Excel and Outlook
• Willingness to work various schedules and adapt to a changing work environment
• Strong communication skills – verbal and written.
• Ability to disseminate and learn information in a short period of time.
• Efficient and accurate use of technology for data entry, documentation, and analysis
• The ability to multi-task and quickly navigate multiple business tools while maintaining quality.
• Proven ability to meet deadlines.
• Ability to make a positive contribution as demonstrated by learning new skills and making suggestions for process/procedure improvement.
• Maintain client and company quality and production standards
• Maintain knowledge of applicable company policies and procedures

To perform this job successfully, the individual must be able to perform each essential duty effectively. The individual must possess advance product knowledge, comprehensive understanding of insurance terminology and definitions, core knowledge of company and department processes and procedures related to the ability to complete job responsibilities/duties in a proficient and professional manner.

Must have knowledge of medical terminology, ability to read and interpret most medical records/notes, ICD-9/10 and CPT/HCPC/CDT coding;
Familiarity with different medical claim forms, i.e. HCFA-1500 and UB04 forms; working knowledge of Insurance Industry and/or Healthcare.

One to Two years…